Want To Revolutionize Health? Enable Physicians, Don't Replace Them

The reality of today’s funding environment for digital health entrepreneurs is that it’s traditional tech investors who have the lion’s share of the money, while most long-time healthcare investors are on the ropes, contending with fleeing LPs and at least the perception of disappointing returns.

While it’s great news that some tech funds seem interested in dipping their toes into the healthcare space, it’s concerning that the investors with the most resources are not necessarily the ones who understand healthcare the best.

Tech investors, in general, are not always comfortable with physicians, and seem much more at home with engineers and developers. These investors also tend to gravitate to businesses selling directly to consumers rather than dealing with the sordid complexities of our current healthcare system.

Many tech investors are also — understandably — drawn to the power of data, and the possibility of analytics, a sensible affinity but one that at times can translate into an excessively reductive view of medicine that fails to capture the maddening but very real ambiguity of medical science, and especially of clinical practice.

While almost everyone contemplating the problems of the current healthcare system acknowledges that often stubborn, intransigent doctors can be part of the problem, it’s arresting how many technologists don’t also view doctors as a key element of the solution; instead, there seems to be a common, techno-utopian vision in which medicine has been profoundly disrupted, and the role of physicians largely replaced by computers – see here (a particularly vivid example), as well as here.

In the words of digital health investor and doctor Bijan Salehizadeh, “IT rooted VCs don’t know how to relate to or speak the language of physicians. They bow at the altar of revolutionary disruption. That works in non-regulated consumer markets. Not in highly regulated hierarchical fragmented spaces like HCIT.”

The more technology investors I speak with, the more I worry there’s something elemental about medicine that many don’t seem to understand – and worse, they don’t always know what they don’t know.

Doctors have a unique perspective

The experience of being a doctor provides unique insight into the meaning and significance of health.

For starters, as a physician, you develop a profound, overwhelming appreciation of how serious health is, and you experience and help patients and their families in dealing with every phase of illness. When I listen to a young entrepreneur extol his or her new approach to saving large files or sharing music as an example of changing the world, I appreciate and love their enthusiasm and passion – how can you not? At the same time, I also find myself reflecting upon other talks I’ve heard – Judah Folkman discussing his discovery of angiogenesis, or Bruce Walker discussing advances in HIV therapy – and I think: now this – this is changing the world.

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Hi Rodrigo- Thanks so much for your always-insightful comments, with which I heartily agree. Piece focused on MDs simply because most of discussion I’ve heard about disruption seems to focus on putative need to get them out of the picture, which I (obviously) believe may be a big mistake. Strongly share view of value of care team collectively, as I deeply believe, and hope I’ve consistently conveyed. Love your comments about emergence! And appreciate your comments about medical/health, or as i’ve also heard it, sickcare (what we are said to have) vs healthcare (which we are said to need). Key balance is motivating healthy behaviors without compelling people to have their entire lives consumed with this pursuit.

I think the conclusions of this piece are just right: more integration, more interest in the clinical process, more collaboration of physicians with tech with design with patients.

We’ve just finished a beta test of a new program for guys who want to get healthy and lose the gut, and group texting, with action-oriented, gender-specific messages was a good part of its success, and really fun.

However, there are two big digital divides that entrepreneurs need help with to offer huge wins: first, VCs are generally not interested in health care digital projects that are small (45) especially have no time for technology, even EMRs, unless it makes their lives easier…like ipads can, for example, to illustrate anatomical details pre-op. No one has to hound a doctor to use an ipad (unlike EMRs, even with huge $ incentives): it’s that easy, fun and value-driven.

That’s also should be health care driven, especially because of its seriousness- easy, fun and value-driven.

Thank you David for an excellent summary of both the successes and shortcomings in the mobile health arena to date. We have noted the bias towards technology over clinical experience based on where the money is flowing. This is part of the reason that Harvard Medical School/Harvard Health Publications has been working with Rock Health since it began, and is pleased to be hosting Rock Health Boston this summer. We hope that by combining the access to the enormous medical community here with the technology and investor network that Rock Health has created, we will be part of addressing this issue you have identified and facilitate a deeper level of innovation.

Ed, thank you so much for your kind comments; I certainly have a passing familiarity with your institution. Delighted to hear about work w/Rock Health, as Boston (even, sadly, without Youk) is obviously a terrific place for their efforts. I expect there will also be opportunities to synchronize with the new institute that I’ve recently co-founded there, together w/Denny Ausiello (who will lead it) and several others from MGH; it’s called the Center for Assessment Technology and Continuous Health (CATCH), and seeks to use enhanced, real-world phenotypic measurement to improve care and drive science; Denny and I outlined some of the thinking in this recent Atlantic piece: http://www.theatlantic.com/health/archive/2012/01/decoding-phenotype-the-holy-grail-for-todays-medical-scientists/251797/ .

You’ve made some interesting points here – including the importance of the doctor/patient relationship and the “scientism” of medical practice. This is critical in understanding the complexities in delivering care. But what I don’t hear in this discussion is the patient voice.

Reticent tech investors may have it right. Enabling doctors and process isn’t revolutionary. Enabling patients may be more radical. And present a much greater market opportunity.

In your article of Oct 11, 2011 “Design Can Improve Healthcare” you highlight some key problems: - medicine is far less “human-centered” — that is, patient-centered — than most observers appreciate - Physicians have surprisingly little visibility into a patient’s day to day health experience

So if physicians have minimal understanding of the patient experience, who’s actually listening to the patient? The NHS in the UK has made the patient voice a central tool for effecting design change. Time and again you’ll hear frontline clinicians talk about using patient stories to inform practice change. There are other initiatives on both sides of the pond. www.patientcommando.com is a diverse collection of patient stories in any media that enrich our understanding of the lived illness experience.

I dare to propose that the most disruptive technology yet to be exploited is the patient story. Not to offend the hordes of 20 something wiz kids developing games that will incentivize health behaviour change, but until they really appreciate what 50% of the population over 45 experiences with lifelong chronic illness, they’ll continue to miss the big win.

Patients are the most underutilized resource in the health care equation. Real empowerment doesn’t come from giving them games, toys or other distractions. Finding the key to empowerment will cause cataclysmic change.

It starts with developing active listening skills. Surveys are good but storytelling gives the storytellers more control, their attention is more focused on the story than the audience, and as they are less self-conscious they provide information that is closer to their private accounts. (Greenhalgh & Hurwitz, 1998).

Its been said that “stories trump data”. Those stories are only going to come from the voice of patients. Making digital health entrepreneurs more conscious of the human-centred needs in product design will open up the doors to opportunities that will trigger the interests of investors. That’s the real challenge.

An inevitable challenge of trying to focus a piece on a particular aspect of an issue is that other important aspects can be perceived as de-emphasized; this was raised by another reader regarding the value of the entire care team (with which I entirely agree), and by you regarding the centrality of patients and the need to better hear the voice of the patient (with which I also entirely agree). In addition to the Atlantic article you reference, you might find these commentaries of interest as well: - http://www.nytimes.com/1995/07/10/opinion/the-bedside-profession.html - http://www.nytimes.com/2000/09/19/opinion/the-right-to-live.html - http://select.nytimes.com/gst/abstract.html?res=F50F11FC3C550C758DDDAD0894D8404482&scp=1&sq=shaywitz%20ausiello%20genes&st=cse - http://www.forbes.com/sites/davidshaywitz/2012/02/07/getting-better-online-communities-elevate-voice-of-the-patient/ - http://www.forbes.com/sites/davidshaywitz/2012/02/10/turning-loss-into-hope-family-offers-inspiration-and-a-few-lessons-about-drug-discovery/ - http://www.forbes.com/sites/davidshaywitz/2012/03/31/medicine-must-allow-for-customization-a-lesson-for-policy-makers-and-regulators/ - http://www.forbes.com/sites/davidshaywitz/2011/09/23/medicines-next-great-challenge-returning-science-to-the-patient/ - http://www.forbes.com/sites/davidshaywitz/2011/07/27/focus-factor-should-your-doctor-be-thinking-about-societys-healthcare-costs/ - http://blogs.forbes.com/davidshaywitz/2011/06/17/what-silicon-valley-doesnt-understand-about-medicine/ - http://blogs.forbes.com/davidshaywitz/2011/06/21/standards-and-medical-practices-a-cautionary-prognosis-for-algorithm-based-care/ - http://www.theatlantic.com/life/archive/2011/10/are-doctors-becoming-obsolete/246439/ - http://www.theatlantic.com/health/print/2012/04/mission-critical-how-disease-specific-foundations-may-save-medical-research/256156/ - http://www.theatlantic.com/health/archive/2012/05/will-patients-bear-the-burden-for-developing-their-own-treatments/256985/

David, This is a great description of the challenges we face to improve healthcare delivery. I founded HealthTech Capital because it takes three sets of expertise to start new healthcare delivery companies: HEALTHCARE (workflow of multiple stakeholders, complex regulatory and payment systems), TECHNOLOGY ENABLERS (mobility and social media are enablers only..we learn these lessons during the internet bubble), and USER ENGAGEMENT (patients, nurse or doctors). Nobody has these three sets of expertise (entrepreneurs or investors). We had to create an ecosystem of providers, clinicians, industry, angel and venture capitalists to bring all these expertise together! unfortunately tech VC fall back to their comfort level which is selling directly to consumers instead of dealing with complexity and irrationality of today’s healthcare delivery. There is a funding gap for selling productivity tools to existing healthcare providers and an overabundance, if not exuberance, of activities for patient empowerment and direct to consumer products and services.

David – this is one of the best commentaries on the topic that I have seen. It is undoubtedly true that non-healthcare investors are (rightfully) cautious about investing in a sector (U.S. healthcare) that is so affected by tradition, guilds, state and federal regulation, politics, unsatisfiable consumer expectations, etc. I have to agree that in this environment smart investors will enable physicians to do a better job. There is no way that physicians can expect to keep up with current patient demand or the growth of medical knowledge without better information resources and tools. Investments that tackle this problem will have success in the current payment system and in a program with rational financial rewards.

From a public health, payor and consumer perspective, though, there is more to gain by enabling consumers to make better choices and health care decisions, since so much of the demand for medical services is driven by lifestyle-driven chronic disease and over-utilzation (much of which is patient-directed). This means bending the curve of behavior and lifestyle which is not a “health” health care business but a “life” business. To do so will require engagement of all the technologies that are so influential in influencing consumer behavior, including marketing reasearch, consumer research and traditional health, wellness & fitness applications.

Both physicians and consumers-as-patients represent good markets for investment. Consumers, employers and other sponsors of health care services want and need the information and systems that enable them to avoid visits to the clinic or hospital. Consultation from an expert (virtual or in-person) will be available at a consumer-afforadable charge (like a legal consultation). When a complex diagnostic or therapeutic problem is faced, the consumer becomes a patient and absolutely needs the right physician who has access to the right information.

To paraphrase the headline to your article, we will “revolutionize healthcare” by enabling physicians AND consumers: physicians to base their diagnostic and therapeutic decisions on the best information available; consumers to avoid the self-inflicted need to visit a clinic or hospital.

Robert, deeply appreciate your thoughtful and well-considered comments, with which I generally feel strongly aligned. I still worry about connecting vague notions of consumer/public wellness with measurable improvements in health that demonstrably bend the cost-curve you describe; it’s not clear to me that the tens of thousands of health/wellness apps currently in circulation have collectively had any sort of measurable impact on either the quality or cost of our nation’s health. I understand the opportunity, but there’s a bit of a chasm to cross here, I believe.